Comparable efficacy of endoscopic transpapillary gallbladder drainage and percutaneous transhepatic gallbladder drainage in acute cholecystitis.

BACKGROUND AND STUDY AIMS: Although endoscopic transpapillary gallbladder drainage (ETGBD) is reportedly useful in patients who have acute cholecystitis, its efficacy has not been compared to that of percutaneous transhepatic gallbladder drainage (PTGBD). We retrospectively compared the efficacy and safety of ETGBD and PTGBD in patients with acute cholecystitis. PATIENTS AND METHODS: We studied 75 patients who required gallbladder drainage for acute cholecystitis between January 2014 and December 2016. Using propensity score matching analysis, we compared the clinical efficacy and length of hospitalization in patients successfully treated with ETGBD and PTGBD. Moreover, we assessed the predictive factors for hospitalization period < 30 days using multivariate analysis. RESULTS: ETGBD and PTGBD were successfully performed in 33 patients (77 %) and 42 patients (100 %) ( P  < 0.001). Twenty-seven matched pairs were obtained after propensity score matching analysis. No significant differences were observed between patients treated with ETGBD and those treated with PTGBD with respect to improvement in white blood cell count and serum C-reactive protein level. The length of hospitalization in patients treated with ETGBD was significantly shorter than in those treated with PTGBD regardless of the need for surgery. Multivariate logistic regression analysis revealed ETGBD (odds ratio, 7.07; 95 % confidence interval 2.22 - 22.46) and surgery (odds ratio 0.26; 95 % confidence interval 0.09 - 0.79) as independent factors associated with hospitalization period. There were no significant differences in occurrence of complications in ETGBD and PTGBD procedure. CONCLUSIONS: ETGBD was shown to be as useful as PTGBD for treatment of acute cholecystitis and was associated with shorter hospitalization period. ETGBD can be an alternative treatment option for acute cholecystitis at times when PTGBD is not possible.

Validity of the Pre-endoscopic Scoring Systems for the Prediction of the Failure of Endoscopic Hemostasis in Bleeding Gastroduodenal Peptic Ulcers.

Objective Although several pre-endoscopic scoring systems have been used to predict the mortality or the need for intervention for upper gastrointestinal bleeding, their usefulness to predict the failure of endoscopic hemostasis in bleeding gastroduodenal peptic ulcers has not yet been fully investigated. In this study, we evaluated the usefulness of the Glasgow-Blatchford score (GBS), the clinical Rockall score (CRS), and the AIMS65 score in predicting the failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. Methods We retrospectively evaluated 226 consecutive emergency endoscopic cases with bleeding gastroduodenal peptic ulcers between April 2010 and September 2016. The study outcome was the failure of first endoscopic hemostasis. The GBS, CRS, and AIMS65 scores were assessed for their ability to predict the failure of endoscopic hemostasis using a receiver-operating characteristic curve. Results Eight cases (3.5%) failed to achieve first endoscopic hemostasis. Surgery was required in six cases, and interventional radiology was required in two cases. The GBS was superior to both the CRS and the AIMS65 score in predicting the failure of endoscopic hemostasis [area under the curve, 0.77 (95% confidence interval, 0.64-0.90), 0.65 (0.56-0.74) and 0.75 (0.56-0.95), respectively]. No failure of endoscopic hemostasis was noted in cases in which the patient scored less than GBS 10 and CRS 2. Conclusion The GBS was the most useful scoring system for the prediction of failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. The GBS was also useful in identifying the patients who did not require surgery or interventional radiology.

Biliary drainage improves the predictive value of modified Glasgow Prognostic Scores in inoperable pancreatic cancer.

OBJECTIVE: To assess the influence of biliary drainage to cholangitis on modified Glasgow Prognostic Score (mGPS) in patients with pancreatic cancer. METHODS: mGPS was calculated before and after biliary drainage in 47 consecutive patients with inoperable pancreatic cancer who were receiving chemotherapy. Biliary drainage was indicated for malignant obstructive jaundice that prevented the administration of chemotherapy. To elucidate mGPS values, serum levels of CRP and albumin were measured at the time of diagnosis (before biliary drainage). Overall survival was evaluated and risk factors, which contribute to overall survival, were examined. RESULTS: Biliary drainage was performed in 15 patients. Using values obtained before biliary drainage, there were no significant differences in median survival time between patients with a mGPS of 0 and those with a mGPS of 1 or 2 (10.7 vs. 9.4 months; p = 0.757). However, using values obtained after biliary drainage, median survival time was significantly higher in patients with a mGPS of 0 than in those with a mGPS of 1 or 2 (11.4 vs. 4.7 months; p = 0.002). Multivariate analysis revealed that a mGPS of 1 or 2 (HR: 3.38; 95% CI: 1.35-8.46, p = 0.009), a carbohydrate antigen 19-9 >1000 U/mL (2.52; 1.22-5.23, p = 0.013), a performance status of 2 (7.68; 2.72-21.28, p = 0.001), carcinoembryonic antigen level >10 ng/mL (2.29; 1.13-4.61, p = 0.021) were independently associated with overall survival. CONCLUSION: mGPS values obtained after biliary drainage appear to be a more reliable indicator of overall survival in patients with inoperable pancreatic cancer.

Perforated emphysematous cholecystitis managed by endoscopic transpapillary gallbladder drainage.

An 88-year-old woman with dementia was diagnosed as having perforated emphysematous cholecystitis with localized peritonitis. Because she was at high risk for surgery, gallbladder drainage was required before surgery. Endoscopic transpapillary gallbladder drainage instead of percutaneous transhepatic biliary drainage was performed because bile could leak from the puncture site to free space around the perforated gallbladder. After the insertion of a nasobiliary drainage tube, the gallbladder was drained and cleaned with saline solution. Subsequently, a nasobiliary drainage tube was replaced with a double-pigtail stent because she was at high risk of dislodging the nasobiliary drainage tube. Although clinical improvement was observed, she was treated conservatively without surgery. She was followed up for 6 months without developing cholecystitis. For perforated cholecystitis without developing panperitonitis, endoscopic transpapillary gallbladder drainage would be an effective option as a bridge to surgery for the initial treatment and as an alternative to surgery for long-term management for a later treatment. This is the first reported case of perforated emphysematous cholecystitis with localized peritonitis treated with endoscopic transpapillary gallbladder drainage.

Usefulness of the Glasgow-Blatchford score to predict 1-week mortality in patients with esophageal variceal bleeding.

OBJECTIVES: Esophageal variceal bleeding is one of the most severe complications of liver cirrhosis, with high mortality. However, there is no established scoring system for short-term mortality in patients with esophageal variceal bleeding. The aim of this study was to evaluate the usefulness of the Glasgow-Blatchford score (GBS), the Model for End-Stage Liver Disease (MELD) score, and the Child-Pugh score for predicting short-term and hospital mortality in patients with esophageal variceal bleeding. METHODS: A total of 47 patients with esophageal variceal bleeding were studied between September 2009 and March 2015. The GBS, the MELD score, and the Child-Pugh score were assessed for their ability to predict 1- and 6-week mortality rates using a receiver operating characteristic curve. RESULTS: The 1- and 6-week mortality rates were 17.0 and 31.9%, respectively. The median GBS, MELD, and Child-Pugh scores were 13 (range: 4-19), 10 (range: 0-34), and 9 (range: 5-13), respectively. The GBS was superior to both the MELD and the Child-Pugh scores for prediction of 1-week mortality [area under the curve=0.82 (95% confidence interval: 0.66-0.98) vs. 0.71 (0.47-0.96) and 0.72 (0.53-0.91)]. The MELD score was superior to both the Child-Pugh score and the GBS for prediction of 6-week mortality [area under the curve=0.83 (95% confidence interval: 0.69-0.97) vs. 0.69 (0.52-0.85) and 0.67 (0.50-0.83)]. CONCLUSION: For 1-week mortality, the GBS was superior to the Child-Pugh and the MELD scores in patients with esophageal variceal bleeding. However, for 6-week mortality, the MELD score was superior in patients with esophageal variceal bleeding.

Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients.

BACKGROUND AND AIM: Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding. METHODS: We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness. RESULTS: Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m2 , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]). CONCLUSION: We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding.

Humoral hypercalcemia due to gastric carcinoma secreting parathyroid hormone-related protein during chemotherapy: a case report.

Humoral hypercalcemia due to a gastric carcinoma-secreting parathyroid hormone-related protein (PTHrP) is a rare disease associated with poor prognosis. A 61-year-old male with gastric cancer who had been receiving chemotherapy showed serum hypercalcemia and an elevated level of serum PTHrP with a suppressed intact parathyroid hormone level. Computed tomography revealed stable disease 4 weeks prior, and the laboratory examination revealed no adverse effects 2 weeks prior. The biopsy at the time of diagnosis was immunohistochemically positive for PTHrP later. Despite intensive care, the patient died of multiorgan failure on the 14th day after admission. In case of undifferentiated gastric cancer, the possibility of humoral hypercalcemia of malignancy caused by gastric cancer should be considered even when the patient is receiving chemotherapy.

Evaluation of the clinical relevance of hrgA gene in patients with Helicobacter pylori infection.

BACKGROUND/AIMS: Patients with gastric cancer in some Asian populations were infected more frequently with hrgA-positive H. pylori. The aim of this study was to examine the usefulness of hrgA to predict the clinical outcome of H. pylori infection. METHODOLOGY: Forty four patients with gastric cancer (35 intestinal and 9 diffuse type cancer) and 51 control subjects were studied. Presence of hrgA gene in H. pylori strains isolated from biopsy specimens was examined by PCR. Biopsy specimens were also obtained for histological assessment of gastritis. RESULTS: Nine of 44 patients with gastric cancer (20.4%) and 11 of 51 control subjects (21.6%) were infected with hrgA-positive strain (NS). In patients with gastric cancer, prevalence of hrgA-positive strain was 20.0% in patients with intestinal type cancer (7/35) and 22.2% with diffuse type cancer (2/9) (NS). In control subjects, the prevalence of hrgA-positive infection was not associated with gastric mucosal inflammatory infiltration and glandular atrophy. CONCLUSIONS: Infection with hrgA-positive strain was not frequent among patients with gastric cancer. Presence of hrgA gene would not be a useful marker to predict clinical outcome of patients infected with H. pylori in this series of Japanese patients.